Provider Demographics
NPI:1780096990
Name:ART OF MOTION CHIROPRACTIC AND SPORTS MEDICINE PLLC
Entity type:Organization
Organization Name:ART OF MOTION CHIROPRACTIC AND SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHALOAM
Authorized Official - Middle Name:AGALELEI
Authorized Official - Last Name:OFISA
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS
Authorized Official - Phone:208-242-3723
Mailing Address - Street 1:1800 FLANDRO DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4912
Mailing Address - Country:US
Mailing Address - Phone:208-242-3723
Mailing Address - Fax:208-904-1052
Practice Address - Street 1:1800 FLANDRO DR
Practice Address - Street 2:SUITE 130
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-4912
Practice Address - Country:US
Practice Address - Phone:208-242-3723
Practice Address - Fax:208-904-1052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1952713166Medicaid